Systems and methods for automated review of risk adjustment data on submitted medical claims

ABSTRACT

Disclosed and described herein are systems and methods of performing computer-aided analysis of health claims to determine if a current claim is consistent with past claims for a member. Consistent claims are directed to a healthcare payor while non-consistent claims are returned for review and/or revision.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.16/368,193, filed Mar. 28, 2019, which is incorporated herein byreference in its entirety.

FIELD OF THE INVENTION

Embodiments of the present invention relate generally to systems andmethods of applying, in real time at the time of submission, comparativeand predictive analytics to the risk adjustment data on a submittedmedical claim and on previously-submitted and archived medical claimsfor the same patient to identify actionable gaps in diagnosis coding.

BACKGROUND

Health plans participating in government sponsored programs including,for example, Medicare Advantage, Managed Medicaid, and the CommercialACA market have an obligation to undertake due diligence to ensure theaccuracy, completeness, and truthfulness of the risk adjustment datathey submit to Centers for Medicare and Medicaid Services (CMS) or otherhealthcare payors (e.g., insurance companies, etc.). This data isprimarily in the form of the diagnosis codes on medical claims.Conventionally, healthcare payors have relied on healthcare providers tocode completely and accurately, but healthcare providers receive paymentbased on the codes that are submitted (including evaluation andmanagement (E&M) (current procedural terminology (CPT) or procedure)codes), so there's a disconnect and not necessarily a shared objectivebetween the healthcare provider and the healthcare payor. And whilehealthcare payors rely on healthcare providers to achieve their goals,healthcare providers are under continued pressures, with reduced feeschedules, programs from multiple payers, and programs are not typicallyaligned with healthcare provider workflows. Furthermore, because of thesheer volume of health claims generated by healthcare providers, it isimpracticable if not impossible for healthcare payors to review, verifyand confirm the diagnosis codes submitted by the healthcare providers tothe healthcare payors in all health claims.

Traditionally, healthcare payors have relied on in-office chart reviewsor requests for medical records so that they can be manually reviewed,which is burdensome to healthcare providers and costly to healthcarepayors. Medical record reviews have other limitations as well. Somehealthcare providers won't comply and won't provide the medical records.Sometimes the records can't be reviewed completely because of deadlines.Health plans may also be constrained by the cost of these reviews. Theconventional approach can delay receiving reimbursement from healthcarepayors up to 12 months for healthcare providers.

Healthcare payors, as an express condition of receiving payment orreimbursement from CMS, must certify, based on best knowledge,information, and belief, that their risk adjustment data they submit toCMS are accurate, complete, and truthful. CMS has made it clear thatMedicare Advantage organizations have an obligation to undertake duediligence to ensure this, and that they are held responsible for makinggood faith efforts.

Therefore, a due diligence tool is desired that overcomes challenges inthe art, some of which are described above, that better ensures accurateand complete coding by engaging healthcare providers within theirexisting billing workflow as the healthcare provider submits a claim.

SUMMARY

Generally, disclosed and described herein are systems and methods thatfor performing computer-aided analysis of health claims, in real time atthe time a claim is submitted, to determine if there are gaps in thediagnosis coding included within the current submitted claim, such thatit is inconsistent with past claims for a member, or with what isexpected for that member. Consistent claims, or claims that includeexpected diagnosis codes, are directed to a healthcare payor whilenon-consistent claims are returned for review and/or revision.

In one aspect, a method is disclosed for performing computer-aidedanalysis of an electronic health claim. One of the embodiments of themethod comprises intercepting, by a computer, an electroniccommunication from a sender to a recipient, where the communicationcomprises at least a portion of a current electronic health claimassociated with a member and the received portion of the currentelectronic health claim includes one or more diagnosis codes. The methodfurther comprises identifying, by the computer, a set of one or moreexpected diagnosis codes, where the set of expected diagnosis codes areassociated with a chronic disease or a chronic condition of the member.The computer determines whether at least one of the set of expecteddiagnosis codes is included in the one or more diagnosis codes of thecurrent electronic health claim. If it is determined that at least oneof the set of expected diagnosis codes is included in the one or morediagnosis codes of the current electronic health claim, the electroniccommunication is transmitted to the recipient. If it is determined thatat least one of the set of expected diagnosis codes is not included inthe one or more diagnosis codes of the current electronic health claim,a message is transmitted to the sender. The message identifies at leastone of the expected diagnosis codes.

In various aspects of the disclosed methods, the sender is a healthcareprovider and the recipient is a healthcare payor.

In some instances, the computer disclosed in the method comprises aclearinghouse and the clearinghouse is configured to communicate claimmessages between the healthcare providers and the healthcare payors and,generally, the steps of the method are performed in real time uponsubmission of the electronic health claim to the clearinghouse.

Alternatively or optionally, identifying the set of expected diagnosiscodes comprises accessing, by the computer, a database of health claims;identifying one or more prior chronic diagnosis codes included in one ormore prior health claims for the member found in the database of healthclaims; determining, by the computer, a chronic disease or a chroniccondition of the member as a chronic condition or chronic diseaseassociated with the one or more prior diagnosis codes, wherein thechronic condition or chronic disease associated with the one or moreprior diagnosis codes is determined by the computer accessing a databaseof mappings that maps diagnosis codes to chronic diseases or chronicconditions; and determining, by the computer, the set of expectedchronic diagnosis codes as all chronic diagnosis codes associated withthe chronic disease or chronic condition of the member as determined bythe mapping of the one or more prior diagnosis codes of the member tothe chronic disease or chronic condition associated with the one or moreprior diagnosis codes using the database of mappings.

In some instances, the chronic disease or chronic condition of themember comprises one or more chronic diseases and/or one or more chronicconditions.

In some instances, when it is determined that at least one of the set ofexpected diagnosis codes is not included in the portion of the currentelectronic health claim, then the computer identifies at least one ofthe expected diagnosis codes to include in the message based on at leastone of frequency of the chronic diagnosis codes found in the priordiagnosis codes or recency of chronic diagnosis codes found in the priordiagnosis codes.

Alternatively or optionally, when accessing the database of healthclaims, the computer only accesses and analyzes health claims associatedwith a defined period of time. For example, the defined time period maycomprise three years prior to a date of the current electronic healthclaim.

Alternatively, or optionally, identifying the set of expected diagnosiscodes comprises the computer accessing a medical claim history of themember to determine a pattern that indicates existence of a potentialchronic disease or chronic condition of the member, and identifying oneor more chronic diagnosis codes associated with the potential chronicdisease or chronic condition using a database of mappings that mapschronic diseases or chronic conditions to chronic diagnosis codes. Theset of expected chronic diagnosis codes are the chronic diagnosis codesmapped to the potential chronic disease or chronic condition of themember. In some instances, the sender comprises a healthcare provider,and the computer further utilizes one or more of a specialty of thehealthcare provider, what other healthcare providers in that specialtyoften diagnose, and/or an amount of time spent by the healthcareprovider with the member when identifying the set of expected diagnosiscodes.

In some instances, when it is determined that at least one of the set ofexpected diagnosis codes is not included in the one or more diagnosiscodes of the current electronic health claim, and before transmittingthe message to the sender, then a database of health claims is accessedby the computer, and the computer determines whether any prior healthclaim associated with the member over a past time period found in thedatabase of health claims included a prior diagnosis code that isincluded in the set of expected diagnosis codes. If it is determinedthat at least one prior diagnosis code is included in the set ofexpected diagnosis codes, then the electronic communication istransmitted to the recipient and the message is not sent to the sender.If it is determined that at least one prior diagnosis code is notincluded in the set of expected diagnosis codes, then the message issent to the sender. For example, the past time period may be one yearprior to a date of the current electronic health claim.

Further disclosed and described herein are systems for implementing themethods disclosed herein.

Other objects and advantages will become apparent to the reader and itis intended that these objects and advantages are within the scope ofthe present invention. To the accomplishment of the above and relatedobjects, this invention may be embodied in the form illustrated in theaccompanying drawings, attention being called to the fact, however, thatthe drawings are illustrative only, and that changes may be made in thespecific construction illustrated and described within the scope of thisapplication.

BRIEF DESCRIPTION OF THE DRAWINGS

Various other objects, features and attendant advantages of the presentinvention will become fully appreciated as the same becomes betterunderstood when considered in conjunction with the accompanyingdrawings, in which like reference characters designate the same orsimilar parts throughout the several views, and wherein:

FIGS. 1A and 1B illustrate exemplary overview block diagrams of systemsfor performing aspects of the disclosed embodiments.

FIG. 2 is a flowchart illustrating an example of a process forperforming computer-aided analysis of an electronic health claim.

FIG. 3 illustrates an exemplary computer or computing device that can beused for some, a portion of, or all of the set of features andcomponents described herein.

DETAILED DESCRIPTION

Before the present methods and systems are disclosed and described, itis to be understood that the methods and systems are not limited tospecific synthetic methods, specific components, or to particularcompositions. It is also to be understood that the terminology used inthis entire application is for the purpose of describing particularembodiments only and is not intended to be limiting.

As used in the specification and the appended claims, the singular forms“a,” “an” and “the” include plural referents unless the context clearlydictates otherwise. Ranges may be expressed herein as from “about” oneparticular value, to “about” another particular value, or from “about”one value to “about” another value. When such a range is expressed,another embodiment includes from the one particular value, to the otherparticular value, or from the one particular value to the otherparticular value. Similarly, when values are expressed asapproximations, by use of the antecedent “about,” it will be understoodthat the particular value forms another embodiment. It will be furtherunderstood that the endpoints of each of the ranges are significant bothin relation to the other endpoint, and independently of the otherendpoint.

“Optional” or “optionally” means that the subsequently described eventor circumstance may or may not occur, and that the description includesinstances where said event or circumstance occurs and instances where itdoes not.

Throughout the description and claims of this specification, the word“comprise” and variations of the word, such as “comprising” and“comprises,” means “including but not limited to,” and is not intendedto exclude, for example, other additives, components, integers or steps.“Exemplary” means “an example of” and is not intended to convey anindication of a preferred or ideal embodiment. “Such as” is not used ina restrictive sense, but for explanatory purposes.

When referring to a diagnosis code that a provider includes on a healthclaim, the plural form of “codes” will be used for brevity but will havethe same meaning as “one or more codes”. In practice, a provider mayassociate more than one diagnosis codes to a health claim.

Use of the word “claim” follows the same style as “diagnosis code,” asit is possible for multiple claims to be submitted, for example, to ahealthcare payor (e.g., a primary and secondary insurer).

Disclosed are components that can be used to perform the disclosedmethods and systems. These and other components are disclosed herein,and it is understood that when combinations, subsets, interactions,groups, etc. of these components are disclosed that while specificreference of each various individual and collective combinations andpermutation of these may not be explicitly disclosed, each isspecifically contemplated and described herein, for all methods andsystems. This applies to all aspects of this application including, butnot limited to, steps in disclosed methods. Thus, if there are a varietyof additional steps that can be performed it is understood that each ofthese additional steps can be performed with any specific embodiment orcombination of embodiments of the disclosed methods.

As will be appreciated by one skilled in the art, the methods andsystems may take the form of an entirely hardware embodiment, anentirely software embodiment, or an embodiment combining software andhardware aspects. Furthermore, the methods and systems may take the formof a computer program product on a computer-readable storage mediumhaving computer-readable program instructions (e.g., computer software)embodied in the storage medium. More particularly, the present methodsand systems may take the form of web-implemented computer software. Anysuitable computer-readable storage medium may be utilized including harddisks, CD-ROMs, DVD-ROMs, optical storage devices, or magnetic storagedevices.

Embodiments of the methods and systems are described below withreference to block diagrams and flowchart illustrations of methods,systems, apparatuses and computer program products. It will beunderstood that each block of the block diagrams and flowchartillustrations, and combinations of blocks in the block diagrams andflowchart illustrations, respectively, can be implemented by computerprogram instructions. These computer program instructions may be loadedonto a general-purpose computer, special purpose computer, or otherprogrammable data processing apparatus to produce a machine, such thatthe instructions which execute on the computer or other programmabledata processing apparatus create a means for implementing the functionsspecified in the flowchart block or blocks.

These computer program instructions may also be stored in acomputer-readable memory that can direct a computer or otherprogrammable data processing apparatus to function in a particularmanner, such that the instructions stored in the computer-readablememory produce an article of manufacture including computer-readableinstructions for implementing the function specified in the flowchartblock or blocks. The computer program instructions may also be loadedonto a computer or other programmable data processing apparatus to causea series of operational steps to be performed on the computer or otherprogrammable apparatus to produce a computer-implemented process suchthat the instructions that execute on the computer or other programmableapparatus provide steps for implementing the functions specified in theflowchart block or blocks.

Accordingly, blocks of the block diagrams and flowchart illustrationssupport combinations of means for performing the specified functions,combinations of steps for performing the specified functions and programinstruction means for performing the specified functions. It will alsobe understood that each block of the block diagrams and flowchartillustrations, and combinations of blocks in the block diagrams andflowchart illustrations, can be implemented by special purposehardware-based computer systems that perform the specified functions orsteps, or combinations of special purpose hardware and computerinstructions.

Additionally, the disclosed system, method and computer-program productcan optionally be implemented within a cloud computing environment, forexample, in order to decrease the time needed to perform the algorithms,which can facilitate processing of a health claim assoftware-as-a-service (SaaS). Cloud computing is well-known in the art.Cloud computing enables network access to a shared pool of configurablecomputing resources (e.g., networks, servers, storage, applications, andservices) that can be provisioned and released with minimal interaction.It promotes high availability, on-demand self-services, broad networkaccess, resource pooling and rapid elasticity. It should be appreciatedthat the logical operations described herein with respect to the variousfigures may be implemented (1) as a sequence of computer implementedacts or program modules (i.e., software) running on a computing device,(2) as interconnected machine logic circuits or circuit modules (i.e.,hardware) within the computing device and/or (3) a combination ofsoftware and hardware of the computing device. Thus, the logicaloperations discussed herein are not limited to any specific combinationof hardware and software. The implementation is a matter of choicedependent on the performance and other requirements of the computingdevice. Accordingly, the logical operations described herein arereferred to variously as operations, structural devices, acts, ormodules. These operations, structural devices, acts and modules may beimplemented in software, in firmware, in special purpose digital logic,and any combination thereof. It should also be appreciated that more orfewer operations may be performed than shown in the figures anddescribed herein. These operations may also be performed in a differentorder than those described herein.

The present methods and systems may be understood more readily byreference to the following detailed description of preferred embodimentsand the Examples included therein and to the Figures and their previousand following description.

OVERVIEW

Described herein are embodiments of a system, method and computerprogram product (including SaaS) offering that provide targeted messagesto healthcare providers based on identified gaps in the diagnosis codingincluded in health claims submitted by those providers. The disclosedembodiments screen health claims before submission to a health plan(i.e., healthcare payor) to generally identify health claims that do notinclude expected or anticipated chronic diagnosis codes. In oneembodiment, this occurs upon receipt of the health claim by aclearinghouse, an intermediary that communicates claims informationbetween healthcare providers to healthcare payors. When such claims areidentified, they are returned to the submitter (e.g., healthcareprovider) to provide an opportunity for medical record review and, ifsupported in the record, for claim editing.

More specifically, embodiments described herein identify the patient(i.e., member) and search for any chronic diagnosis codes previouslydocumented for that member, each diagnosis code being associated with adisease category. Each chronic disease has a number of chronic diagnosiscodes associated with it (e.g., disease A has diagnosis codes 1, 2 and 3associated with it). If the patient's previous charts include chronicdiagnosis codes 1 and 2, the embodiments described herein apply softwareanalytics to look for any of diagnosis codes 1, 2 OR 3 in the currenthealth claim—i.e., not just the specific diagnosis codes found inprevious claims, but any diagnosis codes associated with that disease(disease A). For example, up to three (3) years of the prior claims forthat member and any available medical record data may be searched tofind prior submitted chronic diagnosis codes associated with one/moreidentified chronic diseases. If any chronic diagnosis codes areidentified in the patient's history, embodiments described herein mayfirst determine whether any claims submitted for that patient within thelast year included a chronic diagnosis code associated with the samedisease category as the previously submitted chronic diagnosis codes. Ifnot, disclosed embodiments analyze the current health claim submitted todetermine whether any such chronic diagnosis code is currentlyreported—i.e., a chronic diagnosis code that is associated with achronic disease or disease category that has been identified in thepatient's history. If a chronic diagnosis code associated with anidentified chronic disease is not included on the current claim, and wasnot included in any claim submitted within the last year, apoint-of-submission message is sent to the submitter identifying thehealth claim that requires review, and, for the healthcare provider'sinformation only, the historically documented chronic diagnosis codesthat were expected or anticipated to be present on the current healthclaim.

FIGS. 1A and 1B illustrate exemplary overview block diagrams of systemsfor performing aspects of the disclosed embodiments. In FIGS. 1A and 1B,an electronic health claim is created after a member 100 sees ahealthcare provider 102. Generally, a “member” as used herein is aperson that is properly enrolled and covered by a healthcare plan and iseligible for benefits including payment of or reimbursement forhealthcare related costs by a healthcare payor 104. Generally, thepayments will be sent from the healthcare payor 104 to the healthcareprovider 102, though in some instances the payments may go directly fromthe healthcare payor 104 to the member 100 or in other instances,payments from the healthcare payor 104 to the healthcare provider 102may be reimbursed by the healthcare provider 102 to the member 100. Thehealthcare provider 102 may be a doctor, a group of doctors, aphysician's assistant, a nurse, a hospital, and the like. As usedherein, “payments” include electronic communications of funds from oneelectronic account to another, a written check or other tangiblerepresentation of money such as money orders and the like, or cashtransfers.

The electronic health claim is created by the healthcare provider 102using a computer or computer system under control of the healthcareprovider 102 (a “first computer”). The electronic health claim includesone or more diagnosis codes for the member as determined by thehealthcare provider 102 who saw the member. As non-limiting examples,the diagnosis codes may be standardized codes such as the InternationalClassification of Disease (ICD) codes (e.g., ICD-10) as published by theWorld Health Organization, though it is to be appreciated that othertypes of diagnosis codes may be used. In some instances, the electronichealth claim may comprise an EDI 837 claims file in compliance withHIPAA (Health Insurance Portability and Accountability Act of 1996)requirements. The electronic health claim is used by the healthcareprovider 102 to obtain payment from an insurance company, governmententity or agency (CMS) or other paying entity (i.e., a “healthcarepayor”) 104 for the services and/or products used by the healthcareprovider 102 when seeing and/or treating the member 100.

As shown in FIGS. 1A and 1B, a separate computer or computing system 106(a “second computer”) receives the electronic health claim 108, or atleast a portion of the electronic health claim 108, at the point wherethe healthcare provider 102 submits the claim for payment. Because anelectronic health claim 108 is generally transmitted from a healthcareprovider 102 to a healthcare payor 104, the computer 106 may be said to“intercept” the electronic health claim 108 as it is transmitted fromthe healthcare provider 102 to the healthcare payor 104, though both thehealthcare provider 102 and the healthcare payor 104 are aware of thisinterception and have agreed to it. Generally, the computer 106comprises at least a processor and a memory in communication with theprocessor. Computer-executable instructions are stored on the memory andexecuted by the processor. The portion of the health claim 108 receivedincludes at least the one or more diagnosis codes, informationsufficient to identify the member that the diagnosis codes areassociated with, and identification of the submitter. Generally, thehealth claim 108 or the portion of it is received by the computer 106from the healthcare provider 102. In some instances, the computer 106 isoperated by, for, and/or under the control of a health claimclearinghouse. In medical billing, companies that function asintermediaries who communicate claims information between healthcareproviders and healthcare payors are known as clearinghouses. In what iscalled claims scrubbing, clearinghouses check health claims for errors.

In FIG. 1A, a healthcare provider 102 sees a member 100 and creates anelectronic health claim 108, which is electronically transmitted to thecomputer 106. The health claim 108 contains information sufficient toidentify the member 100, diagnosis codes associated with the member's100 visit to the healthcare provider 102, information sufficient toidentify the healthcare provider 102 that served the member 100 andsubmitted the health claim 108, and information sufficient to identifythe healthcare payor 104 associated with the member 100. Once the healthclaim 108 is received by the computer 106, it is determined if thehealth claim 108 is associated with a member 100 covered by a healthcareplan for which the healthcare payor 104 wants the health claim 108reviewed. If so, then information is extracted from the health claim 108to find prior health claims submitted in association with that member.Various information from the health claim 108 may be used to look forprior health claims 108 for that member 100. For example, the healthclaim 108 may include an identifier (ID) for the insured (the insuredmay be the same person as the member 100 or may be a dependent or haveanother relationship with the member 100 such that the insured iscovered by the member's 100 health plan (i.e., the patient)). Theinsured's identifier, the patient's date of birth (DOB), and all orportions of the patient's first and last name may be used in variouscombinations to search a database 110 of prior claims for informationabout prior claims submitted in association with the patient. If thehealth claim 108 received by the computer 106 is determined to be ahealth claim 108 that is not associated with a member 100 covered by ahealthcare plan for which the healthcare payor 104 wants the healthclaim 108 reviewed, then the health claim 108 is returned to the sender(e.g., the healthcare provider 102), or is forwarded on to thehealthcare payor 104, or is otherwise treated in accordance with rulesestablished by the clearinghouse.

If information related to prior claims submitted in association with thepatient is found in the database 110 of prior claims, then the priordiagnosis codes for that patient are determined from the database 110.Certain of all diagnosis codes are identified as chronic diagnosiscodes, meaning that they are diagnosis codes associated with chronicdiseases or conditions, where each chronic disease or condition may havemore than one diagnosis code associated or mapped therewith. Forexample, the disease category of diabetes may have one chronic diagnosiscode for “diabetes without complications” and another for “diabetes withcomplications.” These chronic diagnosis codes may be developed accordingto regulatory risk adjustment models, which are primarily based onchronic conditions, though some acute conditions may also be included.The computer 106 has access to a table 120 that identifies chronicdiagnosis codes (i.e., diagnosis codes associated with or mapped tospecific chronic diseases or conditions). If at least some of the priordiagnosis codes for that patient that are retrieved from the database110 are determined to be chronic diagnosis codes associated with atleast one chronic disease, then the computer 106 of one embodiment firstdetermines if any health claims 108 submitted for that member within thelast predetermined period of time (e.g., one year) include a chronicdiagnosis code associated with/mapped to that chronic disease. If not,the computer 106 further determines if the current health claim 108includes a chronic diagnosis code associated with/mapped to thepreviously reported chronic disease or disease category. As notedherein, the health claim 108 is generally a formatted electroniccommunication (e.g. an EDI 837 claims file), where the diagnosis codesare formatted and identified in the health claim 108, thus making themreadily identifiable in the health claim 108.

If none of the chronic diagnosis codes associated with/mapped to anidentified chronic disease for that patient are found on the currenthealth claim 108, then a message 112 is electronically transmitted tothe sender (e.g. healthcare provider 102) that submitted the currenthealth claim 108. In some instances, the message 112 identifies chronicdiagnosis codes that were expected or anticipated to be present in thecurrent health claim 108 based on the prior health claims associatedwith that patient that are found in the database 110. In some instances,only a few of the chronic diagnosis codes that were expected oranticipated to be present in the current health claim 108 are includedin the message 112. Also, in some instances, only a predetermined timeperiod is used to look for prior chronic diagnosis codes associated witha patient in reverse chronological order in the database 110. Forexample, five chronic diagnosis codes may be found in the database 110associated with the patient in a search of the database 110 that extendsto a three-year look-back. If none of these five prior chronic diagnosiscodes are included in the current health claim 108, then perhaps only asubset of the five found prior chronic diagnosis codes will be includedin the message 112. The subset of chronic diagnosis codes selected toreturn in the message 112 may be based on recency, frequency, severityof the disease associated with the chronic diagnosis code(s), etc. Insome instances, the subset comprises two expected chronic diagnosiscodes, though more or fewer numbers of expected chronic diagnosis codesmay be included in the message.

The message 112 may also include a request for the healthcare provider102 to review and resubmit the health claim 108. If the healthcareprovider 102 resubmits the health claim 108, it will be identified as are-submission and the re-submitted diagnosis codes will be reviewed bythe computer 106 to determine if they are chronic diagnosis codes thatwere previously associated with that patient in the database 110, if thecurrent diagnosis codes associated with the health claim 108 areassociated with chronic diagnosis codes that have not been previouslyassociated with that patient in the database 110, if they are the samechronic diagnosis codes as were suggested to the healthcare provider 102in the message, and/or if they are the same diagnosis codes as werepreviously submitted in the earlier-submitted health claim 108.

If the re-submitted diagnosis codes are chronic diagnosis codes thatwere previously associated with that patient in the database 110, thenthe health claim 108 is marked as having been checked for errors and iselectronically transmitted as an electronic communication 114 to thehealthcare payor 104. If the re-submitted diagnosis codes associatedwith the health claim 108 are associated with chronic diagnosis codesthat have not been previously associated with that patient in thedatabase 110, but are found in the table 120 of chronic diagnosis codes,then the health claim 108 is marked as having been checked for errorsand is electronically transmitted to the healthcare payor 104 as anelectronic communication 114. If the re-submitted diagnosis codes arethe same chronic diagnosis codes as were previously suggested in themessage 112 back to the healthcare provider 102, then this is noted andstored in a memory associated with the computer 106 (this may be storedin the database 110 or in other memory), and the health claim 108 ismarked as having been checked for errors and is electronicallytransmitted to the healthcare payor 104 as an electronic communication114. If the re-submitted health claim 108 still does not include anychronic diagnosis codes that have been previously associated with thepatient (as determined by a search of the database 110) but does includea diagnosis code that is found in the table 120 of chronic diagnosiscodes, then this is noted and stored in a memory associated with thecomputer 106 (this may be stored in the database 110 or in othermemory). The health claim 108 is then passed on to the healthcare payor104 in an electronic communication 114, but the electronic communication114 may include a message that the re-submitted health claim 108includes a chronic diagnosis code, but does not include any chronicdiagnosis codes that have been previously associated with the patient.

The message 112 transmitted to the healthcare provider 102 creates anobligation for the healthcare provider 102 to review the medical recordof the patient and to ensure that, to the best of the healthcareprovider's 102 knowledge, information and belief, the submitted claimsare accurate, complete and truthful. The subset of chronic diagnosiscodes selected to return in the message offers assurance to health careproviders 102 that diagnosis codes are not overlooked in the heath claim108 and makes chart review more efficient.

In some instances, the message 112 to the healthcare provider 102 and/orthe electronic communication 114 to the healthcare payor 104 comprisesall or a part of an ANSI X12 EDI 277 CA (claims acknowledgment)transaction. The EDI 277 Health Care Claim Status Response transactionset is used by healthcare payers (insurance companies, Medicare, etc.)to report on the status of claims (837 transactions) previouslysubmitted by providers. The 277 transaction has been specified by HIPAAfor the submission of claim status information. In some instances, theexpected chronic diagnosis codes are returned in a text field of the EDI277CA communication.

In some instances (see FIG. 1B), an electronic communication 114 may beelectronically transmitted to the healthcare provider 102 with anexplanation of the review of the health claim 108 performed by thecomputer 106. In some instances the electronic communication 114includes an indication that the current electronic health claim is validand the healthcare provider 102 in turn submits the validated healthclaim 116 directly to the healthcare payor 104. For example, the currentelectronic health claim may be indicated as being validated by using anelectronic indicator, a syntactical code, and the like that define thatthe health claim was “accepted” and submitted to the healthcare payor104 for adjudication. Alternatively, or optionally, the electroniccommunication 114 may be electronically transmitted to the healthcarepayor 104 with an indication that the current health claim 108 is validand for the healthcare payor 104 to adjudicate 118 the electronic healthclaim 108. Such adjudication may include payment of all or a portion ofthe amount associated with the health claim 108.

In other instances (not shown in FIGS. 1A or 1B) an electroniccommunication 114 may be electronically transmitted to the healthcarepayor 104 with an explanation of the analysis of the health claim 108performed by the computer 106 and/or a request to review and re-submitthe current electronic health claim 108. The healthcare payor 104 wouldthen contact the healthcare provider 102 with a request to review andre-submit the current electronic health claim 108. As with the above,the e electronic communication transmitted to the healthcare payor 104may also include the one or more expected or anticipated chronicdiagnosis codes that were missing from the original health claim 108submission. Such an electronic communication 114 to the healthcare payor104 pay be done with a message 112 of the same information to thehealthcare provider 102, or alone without a message 112 to thehealthcare provider 102.

According to yet another embodiment, the computer 106, using machinelearning and other predictive analytics tools, identifies one or morechronic diagnosis codes that likely should have been included within thecurrent health claim 108 but where not. For example, the computer 106may access the member's medical claim history, which includesinformation on tests run, lab results received, medications prescribed,and the like, to look for patterns of behavior that indicate the likelyexistence of a chronic disease. Where a pattern is identified, and thecurrent health claim 108 does not include a diagnosis code associatedwith that chronic disease, a message 112 may be communication to thehealthcare provider 102, even though the prior health claims 108associated with the member similarly do not include diagnosis codesassociated with that chronic disease. Other factors associated with thehealthcare provider 102 may also be taken into consideration whenpredicting that a chronic diagnosis code is likely missing from a healthclaim 108. For example, embodiments may take into consideration thespecialty of the healthcare provider 102 and what other providers inthat specialty often diagnosis, the time spent with the member 100,and/or the like.

In the exemplary systems shown in FIGS. 1A and 1B, health claims 108,messages 112 and electronic communications 114 may be received,processed and payments transmitted or authorized using a computer orcomputer system under the control of the healthcare payor 104 (a “thirdcomputer”). Electronic communications between the first, second and/orthird computer occur using networks (wired (including fiber optic),wireless, or combinations of wired and wireless). For example, at leasta portion of the network may comprise the internet and/or a virtualprivate network (VPN) using the internet.

If the database 110 of prior health claims is searched and no priorclaim is found that is associated with the member 100, then at least theone or more diagnosis codes of the current health claim 108 can beassociated with the member and stored in the database 110 along withinformation identifying the member 100, the submitting healthcareprovider 102, and the healthcare plan to which that member 100 belongs.In some instances the diagnosis codes stored in the database 110 arechronic diagnosis codes, as described herein. In some instances, thecurrent diagnosis codes may not be associated with a chronic disease orcondition, as determined by a search of the table 120 of chronicdiagnosis codes by the computer 106. Generally, in such an instance, thediagnosis codes of the current health claim 108 are not stored in thedatabase 110. An electronic message can be electronically transmitted toone or both of the healthcare provider 102 or the healthcare payor 104that no prior claims associated with the member were found and/or noneof the current diagnosis codes are found in the table 120 of chronicdiagnosis codes.

Auditing

As noted herein, the computer 106 tracks health claim 108 submissions,messages 112, and electronic communications 114. The computer 106 maytrack whether a specific healthcare provider 102 or healthcare payor 104submits health claims 108 that are missing chronic diagnosis codesand/or have incorrect diagnosis codes. The computer 106 may also trackwhether a specific healthcare provider 102 or healthcare payor 104re-submits health claims 108 upon receiving a message 112 that suggestsexpected chronic diagnosis codes, where the re-submitted chronicdiagnosis codes are comprised of the chronic diagnosis codes that weresuggested to the healthcare provider 102. The computer 106 may alsotrack whether a specific healthcare provider 102 re-submits healthclaims 108 upon receiving a message 112 that expected chronic diagnosiscodes are missing and the re-submitted diagnosis codes are consistentlycomprised of a small set of the same chronic diagnosis codes used overand over for different patients. The computer 106 may also track whethera specific healthcare provider 102 has a higher incidence rate than anaverage of some other healthcare providers 102 of submitting healthclaims 108 that are missing chronic diagnosis codes and/or haveincorrect diagnosis codes. These are only non-limiting examples of theanalytics that can be performed by the computer 106 in tracking healthclaim 108 submissions, messages 112, and electronic communications 114,and the information included with the messages 112 and/or electroniccommunications 114. These analytics can be used to trigger audits of theoffending healthcare providers' 102 and/or healthcare payors' 104practices and procedures in creating, submitting and managing healthclaims 108. Such analytics can be used to detect insurance fraud or justcareless (and inefficient) practices and procedures.

Processes and Methods

FIG. 2 is a flowchart illustrating an example of a process forperforming computer-aided analysis of an electronic health claim. At202, at least a portion of a current electronic health claim for amember sent as an electronic communication between a sender and areceiver is intercepted by a computer. The intercepted and receivedportion of the current electronic health claim includes one or morecurrent diagnosis codes, information sufficient to identify theassociated member, and information to identify the sender and therecipient. At 204, a determination is made if the member is associatedwith a healthcare plan (e.g., healthcare payor) that desires a review ofchronic conditions of the member. If, at 204, a determination is madethat the member is not associated with a healthcare plan (e.g.,healthcare payor) that desires a review of chronic conditions of themember, then at 208 the health claim is treated in accordance withnon-member rules, which may include returning the health claim to thesender, forwarding it on to the recipient (e.g., a healthcare payor,without any additional analysis of the health claim), or simply ignoringthe health claim.

If, at 204, it is determined that the member is associated with ahealthcare plan that desires a review of chronic conditions of themember, then at 206 the computer identifies a set of one or moreexpected diagnosis codes that are associated with a chronic disease orcondition of the member. In one embodiment, this is done using adatabase of health claims that is analyzed by the computer to identify aset of one or more expected diagnosis codes, where the set of expecteddiagnosis codes are associated with a chronic disease or a chroniccondition of the member. In particular, each of the one or more priorhealth claims stored in the database of health claims that areassociated with the member include one or more prior diagnosis codesassociated with the member. The database of health claims includesidentifying information for a plurality of members and the one or moreprior diagnosis codes associated with prior health claims of each of theplurality of members. The database is created from information receivedfrom a plurality of healthcare providers and/or a plurality ofhealthcare payors. The diagnosis codes stored in the database of healthclaims include chronic diagnosis codes associated with and mapped tochronic diseases and/or conditions of the member.

In one embodiment, in order to identify the set of one or more expecteddiagnosis codes, the computer first analyzes the prior health claims ofthe member to identify the prior diagnosis codes included within thoseprior health claims. The computer may then determine one or more chronicdiseases or conditions associated with/mapped to the identified priordiagnosis codes and, therefore, associated with the member. Finally, thecomputer may identify the full set of diagnosis codes associated withthat chronic disease(s) or condition(s) as the set of expected diagnosiscodes.

In other instances, the computer identifies the set of one or moreexpected diagnosis codes that likely should have been included withinthe current health claim by, for example, the computer accessing themember's medical claim history, which includes information on tests run,lab results received, medications prescribed, and the like, to look forpatterns of behavior that indicate the likely existence of a chronicdisease, and then identifying as the set of expected diagnosis codes thefull set of diagnosis codes associated with that chronic disease.

Other factors associated with the healthcare provider may also be takeninto consideration by the computer when identifying the set of one ormore expected diagnosis codes. For example, consideration may be givenby the computer as to the specialty (oncologist, etc.) of the sender andwhat other providers in that specialty often diagnose, the time spentwith the member, and/or the like.

At 210 it is determined, by the computer, whether or not at least one ofthe set of expected diagnosis codes is included in the one or morediagnosis codes of the current electronic health claim. If, at 210, itis determined that at least one of the set of expected diagnosis codesis included, then the process goes to 212. At 212, the computertransmits the electronic communication to the recipient. Generally, thiscomprises an electronic transmission to a healthcare payor with anindication for the healthcare payor to adjudicate the electronic healthclaim. At 214, when it is determined at 210 that at least one of the setof expected diagnosis codes is not included in the current electronichealth claim, a message is transmitted to the sender. The messageidentifies at least one of the expected diagnosis codes.

In some instances, the computer determining whether at least one of theset of expected diagnosis codes is included in the current health claimcomprises confirming whether at least one of the current diagnosis codescorresponds to a chronic disease for which one or more diagnosis codeswere found in prior claims for the member. Alternatively, where the setof expected diagnosis codes was determined based on an identifiedpattern, and the current health claim does not include a diagnosis codeassociated with that chronic disease, a message may be communicated tothe sender identifying at least some of the expected chronic diagnosiscodes, even though the prior health claims associated with the membersimilarly do not include diagnosis codes associated with that chronicdisease.

In some instances, the message transmitted to the sender includes, alongwith the at least one expected chronic diagnosis code, an explanation ofthe reason the health claim is being returned, and/or a request toreview and re-submit the current electronic health claim.

In some instances, when it is determined by the computer that at leastone of the set of expected diagnosis codes is included in the portion ofthe electronic health claim, then the electronic communication istransmitted by the computer back to the sender (rather than to therecipient). In such instances, an indication can be provided that thecurrent electronic health claim is valid, and the healthcare providersubmits the validated health claim directly to the recipient (e.g.,healthcare payor). For example, the current electronic health claim maybe indicated as being validated by using an electronic indicator, asyntactical code, and the like that define that the health claim was“accepted” and can be submitted to the healthcare payor foradjudication.

In instances where the healthcare provider received a message indicatingthat expected diagnosis codes are missing, the healthcare provider mayre-submit the health claim. Such a resubmission may have an indicatorthat it is a re-submitted health claim, as described herein.

Computing Environment

FIG. 3 illustrates an exemplary computer or computing device that can beused for some, a portion of, or all of the features and/or componentsdescribed herein. All or a portion of the device shown in FIG. 3 maycomprise all or any portion of any of the components and devicesdescribed herein that may include and/or require a processor orprocessing capabilities such as the first computer, the second computer,the third computer, etc. As used herein, “computer” may include aplurality of computers. The computers may include one or more hardwarecomponents such as, for example, a processor 321, a random-access memory(RAM) module 322, a read-only memory (ROM) module 323, a storage 324, adatabase 325, one or more input/output (I/O) devices 326, and aninterface 327. Alternatively, and/or additionally, the computer mayinclude one or more software components such as, for example, acomputer-readable medium including computer executable instructions forperforming a method or methods associated with the exemplaryembodiments. It is contemplated that one or more of the hardwarecomponents listed above may be implemented using software. For example,storage 324 may include a software partition associated with one or moreother hardware components. It is understood that the components listedabove are exemplary only and not intended to be limiting.

Processor 321 may include one or more processors, each configured toexecute instructions and process data to perform one or more functionsassociated with a computer for performing computer-aided analysis of anelectronic health claim. Processor 321 may be communicatively coupled toRAM 322, ROM 323, storage 324, database 325, I/O devices 326, andinterface 327. Processor 321 may be configured to execute sequences ofcomputer program instructions to perform various processes. The computerprogram instructions may be loaded into RAM 322 for execution byprocessor 321.

RAM 322 and ROM 323 may each include one or more devices for storinginformation associated with operation of processor 321. For example, ROM323 may include a memory device configured to access and storeinformation associated with the computer, including information foridentifying, initializing, and monitoring the operation of one or morecomponents and subsystems. RAM 322 may include a memory device forstoring data associated with one or more operations of processor 321.For example, ROM 323 may load instructions into RAM 322 for execution byprocessor 321.

Storage 324 may include any type of mass storage device configured tostore information that processor 321 may need to perform processescorresponding with the disclosed embodiments. For example, storage 324may include one or more magnetic and/or optical disk devices, such ashard drives, CD-ROMs, DVD-ROMs, or any other type of mass media device.

Database 325 may include one or more software and/or hardware componentsthat cooperate to store, organize, sort, filter, and/or arrange dataused by the computer and/or processor 321. For example, database 325 maystore information and instructions related to prior health claims madeby a member including information sufficient to identify the member anddiagnosis codes associated with the health claim (and the member). It iscontemplated that database 325 may store additional and/or differentinformation than that listed above.

I/O devices 326 may include one or more components configured tocommunicate information with a user associated with computer. Forexample, I/O devices may include a console with an integrated keyboardand mouse to allow a user to maintain the database of prior healthclaims, and the like. I/O devices 326 may also include a displayincluding a graphical user interface (GUI) for outputting information ona monitor. I/O devices 326 may also include peripheral devices such as,for example, a printer for printing information associated with thecomputer, a user-accessible disk drive (e.g., a USB port, a floppy,CD-ROM, or DVD-ROM drive, etc.) to allow a user to input data stored ona portable media device, a microphone, a speaker system, or any othersuitable type of interface device.

Interface 327 may include one or more components configured to transmitand receive data via a communication network, such as the Internet, alocal area network, a workstation peer-to-peer network, a direct linknetwork, a wireless network, or any other suitable communicationplatform. For example, interface 327 may include one or more modulators,demodulators, multiplexers, demultiplexers, network communicationdevices, wireless devices, antennas, modems, and any other type ofdevice configured to enable data communication via a communicationnetwork.

As noted herein, the computer or computing device illustrated in FIG. 3may comprise all or a part of a cloud computing environment.

While the methods and systems have been described in connection withpreferred embodiments and specific examples, it is not intended that thescope be limited to the particular embodiments set forth, as theembodiments herein are intended in all respects to be illustrativerather than restrictive.

Unless otherwise expressly stated, it is in no way intended that anymethod set forth herein be construed as requiring that its steps beperformed in a specific order. Accordingly, where a method claim doesnot actually recite an order to be followed by its steps or it is nototherwise specifically stated in the claims or descriptions that thesteps are to be limited to a specific order, it is no way intended thatan order be inferred, in any respect. This holds for any possiblenon-express basis for interpretation, including: matters of logic withrespect to arrangement of steps or operational flow; plain meaningderived from grammatical organization or punctuation; the number or typeof embodiments described in the specification.

Throughout this application, various publications may be referenced. Thedisclosures of these publications in their entireties are herebyincorporated by reference into this application in order to more fullydescribe the state of the art to which the methods and systems pertain.

It will be apparent to those skilled in the art that variousmodifications and variations can be made without departing from thescope or spirit. Other embodiments will be apparent to those skilled inthe art from consideration of the specification and practice disclosedherein. It is intended that the specification and examples be consideredas exemplary only, with a true scope and spirit being indicated by thefollowing claims.

What is claimed is:
 1. A method for performing computer-aided analysisof an electronic health claim to facilitate certification that riskadjustment data submitted to the Center for Medicare and MedicaidServices (CMS) is accurate, complete, and truthful, the methodcomprising: receiving, by a computer, an electronic communicationtransmitted from a sender, the electronic communication comprising atleast a portion of a current electronic health claim associated with amember, the portion of the current electronic health claim including oneor more diagnosis codes associated with the member and an identifier forthe member; determining, by the computer, whether the member is coveredby a health care plan provided by a payor by querying a database ofprior electronic health claims using the identifier, wherein thedatabase comprises information from at least one of a plurality ofhealthcare providers and a plurality of healthcare payors; identifying,by the computer and responsive to determining that the member is coveredby the health care plan, a set of expected diagnosis codes for thecurrent electronic health claim by querying an electronic medicalhistory of the member stored in the database, said set of expecteddiagnosis codes associated with a chronic disease or a chronic conditionof the member and identified by: querying the electronic medical historyfor previously submitted diagnosis codes associated with the member, andresponsive to identifying at least one previously submitted diagnosiscode, determining a chronic condition associated with the at least onepreviously submitted diagnosis code, wherein the set of expecteddiagnosis codes are mapped to the chronic condition in the database;determining, by the computer, whether at least one of the set ofexpected diagnosis codes is included in the one or more diagnosis codesof the current electronic health claim; when it is determined that atleast one of the set of expected diagnosis codes is included in the oneor more diagnosis codes of the current electronic health claim,transmitting the electronic communication to the payor, wherein thepayor: i) certifies the risk adjustment data associated with theelectronic health claim is accurate, complete and truthful based on thedetermination that at least one of the set of expected diagnosis codesis included in the one or more diagnosis codes of the current electronichealth claim, and ii) submits data associated with the certifiedelectronic health claim to the CMS for reimbursement; and when it isdetermined that at least one of the set of expected diagnosis codes isnot included in the one or more diagnosis codes of the currentelectronic health claim, then: not sending the electronic communicationto the payor, transmitting a message to the sender identifying theexpected diagnosis codes, and tracking an incident rate for the senderby updating the database to include an indication that the currentelectronic health claim was missing the at least one of the set ofexpected diagnosis codes, wherein the incident rate for the sender iscompared to incident rates of other healthcare providers to trigger anaudit of the sender's practices and procedures.
 2. The method of claim1, wherein the sender is a healthcare provider and the recipient is ahealthcare payor.
 3. The method of claim 2, wherein the computercomprises a clearinghouse and the clearinghouse is configured tocommunicate claim messages between healthcare providers and healthcarepayors.
 4. The method of claim 1, wherein when it is determined that atleast one of the set of expected diagnosis codes is not included in theportion of the current electronic health claim, then the method furthercomprises the computer identifying at least one of the expecteddiagnosis codes to include in the message based on at least one offrequency of the chronic diagnosis codes found in the prior diagnosiscodes or recency of chronic diagnosis codes found in the prior diagnosiscodes.
 5. The method of claim 1, wherein when accessing, by thecomputer, the database of health claims, the computer only accesses andanalyzes health claims associated with a defined period of time.
 6. Themethod of claim 1, wherein identifying the set of expected diagnosiscodes comprises: querying, by the computer, the electronic medicalhistory of the member to determine a pattern that indicates existence ofa potential chronic disease or chronic condition of the member; andidentifying, by the computer, one or more chronic diagnosis codesassociated with the potential chronic disease or chronic condition usingthe database which includes mappings of chronic diseases or chronicconditions to chronic diagnosis codes.
 7. The method of claim 6, whereinthe sender is a healthcare provider, and wherein the computer furtherutilizes one or more of a specialty of the healthcare provider, whatother healthcare providers in that specialty often diagnose, and/or anamount of time spent by the healthcare provider with the member whenidentifying the set of expected diagnosis codes.
 8. The method of claim1, wherein when it is determined that at least one of the set ofexpected diagnosis codes is not included in the one or more diagnosiscodes of the current electronic health claim, and before transmittingthe message to the sender, then: accessing, by the computer, theelectronic medical history of the member; determining, by the computer,whether any prior health claim associated with the member over a pasttime period found in the database of health claims include at least oneof the previously submitted diagnosis codes that are included in the setof expected diagnosis codes; when it is determined, by the computer,that at least one prior diagnosis code is included in the set ofexpected diagnosis codes, then transmitting the electronic communicationto the recipient computer of the recipient and not sending the messageto the sender computer of the sender; and when it is determined, by thecomputer, that at least one prior diagnosis code is not included in theset of expected diagnosis codes, then sending the message to the sendercomputer of the sender.
 9. The method of claim 1, wherein when it isdetermined that at least one of the set of expected diagnosis codes isnot included in the one or more diagnosis codes of the currentelectronic health claim, then: accessing, by the computer, theelectronic medical history of the user to identify past health claimsassociated with the member and the previously submitted diagnosis codesassociated with the past health claims; and determining the set ofexpected diagnosis codes to include in the message based on at least oneof frequency of chronic diagnosis codes found in the previouslysubmitted diagnosis codes, or recency of chronic diagnosis codes foundin the previously submitted diagnosis codes.
 10. A system for performingcomputer-aided analysis of an electronic health claim to facilitatecertification that risk adjustment data submitted to the Center forMedicare and Medicaid Services (CMS) is accurate, complete, andtruthful, the system comprising: a processor; and memory havinginstructions stored thereon that, when executed by the processor, causethe system to: receive an electronic communication from a sendercomputer, wherein the electronic communication includes a currentelectronic health claim associated with a member, the electronic healthclaim including one or more diagnosis codes associated with the memberand an identifier for the member; determine whether the member iscovered by a health care plan provided by a healthcare payor by queryinga database of prior electronic health claims using the identifier,wherein the database comprises information from a plurality ofhealthcare providers and/or a plurality of healthcare payors; responsiveto determining that the member is covered by the health care plan,predict a set of one or more expected diagnosis codes associated with achronic disease or a chronic condition of the member for the currentelectronic health claim based on an electronic medical history of themember stored in the database, the set of expected diagnosis codespredicted by causing the system to: i) query the electronic medicalhistory for previously submitted diagnosis codes associated with themember, and ii) responsive to identifying at least one previouslysubmitted diagnosis code, determine a chronic condition associated withthe at least one previously submitted diagnosis code, wherein the set ofexpected diagnosis codes are mapped to the chronic condition in thedatabase; determine whether at least one of the set of expecteddiagnosis codes is included in the one or more diagnosis codes of thecurrent electronic health claim; when it is determined that at least oneof the set of expected diagnosis codes is included in the one or morediagnosis codes of the current electronic health claim, transmit theelectronic communication to a recipient computer associated with thehealthcare payor, wherein the healthcare payor: i) certifies the riskadjustment data associated with the electronic health claim is accurate,complete and truthful based on the determination that at least one ofthe set of expected diagnosis codes is included in the one or morediagnosis codes of the current electronic health claim, and ii) submitsdata associated with the certified electronic health claim to the CMSfor reimbursement; and when it is determined that at least one of theset of expected diagnosis codes is not included in the one or morediagnosis codes of the current electronic health claim, then: not sendthe electronic communication to the recipient computer, transmit amessage to the sender computer, the message identifying at least one ofthe expected diagnosis codes, and track an incident rate for ahealthcare provider that operates the sender computer by updating thedatabase to include an indication that the current electronic healthclaim was missing the at least one of the set of expected diagnosiscodes, wherein the incident rate for the healthcare provider thatoperates the sender computer is compared to incident rates of other onesof the plurality of healthcare providers healthcare providers to triggeran audit of the healthcare provider's practices and procedures.
 11. Thesystem of claim 10, wherein the sender computer is associated with ahealthcare provider and the recipient computer is associated with ahealthcare payor.
 12. The system of claim 10, wherein the system is aclearinghouse and wherein the electronic communication is intercepted asit is transmitted between the sender computing and the recipientcomputer.
 13. The system of claim 10, the instructions further causingthe system to: identify, responsive to a determination that at least oneof the set of expected diagnosis codes is not included in the portion ofthe current electronic health claim, at least one of the expecteddiagnosis codes to include in the message based on at least one offrequency of the chronic diagnosis codes found in the prior diagnosiscodes or recency of chronic diagnosis codes found in the prior diagnosiscodes.
 14. The system of claim 13, wherein accessing the database ofhealth claims comprises only accessing and analyzing health claimsassociated with a defined period of time.
 15. The system of claim 10,wherein identifying the set of expected diagnosis codes comprises:accessing a medical claim history of the member to determine a patternthat indicates existence of a potential chronic disease or chroniccondition of the member; and identifying one or more chronic diagnosiscodes associated with the potential chronic disease or chronic conditionusing the database which includes mappings of chronic diseases orchronic conditions to chronic diagnosis codes.
 16. The system of claim15, wherein the sender computer is associated with a healthcare providerand wherein at least one of specialty of the healthcare provider, whatother healthcare providers in that specialty often diagnose, and/or anamount of time spent by the healthcare provider with the member isutilized when identifying the set of expected diagnosis codes.
 17. Thesystem of claim 10, wherein when it is determined that at least one ofthe set of expected diagnosis codes is not included in the one or morediagnosis codes of the current electronic health claim, and beforetransmitting the message to the sender computer, the instructionsfurther cause the system to: access the electronic medical history ofthe member; determine whether any prior health claim associated with themember over a past time period found in the database of health claimsinclude at least one of the previously submitted diagnosis code that isincluded in the set of expected diagnosis codes; when it is determinedthat at least one prior diagnosis code is included in the set ofexpected diagnosis codes, then transmitting the electronic communicationto the recipient computer and not sending the message to the sendercomputer; and when it is determined that at least one prior diagnosiscode is not included in the set of expected diagnosis codes, thensending the message to the sender computer.
 18. The system of claim 10,wherein when it is determined that at least one of the set of expecteddiagnosis codes is not included in the one or more diagnosis codes ofthe current electronic health claim, the instructions further cause thesystem to: access the electronic medical history of the user to identifypast health claims associated with the member and the previouslysubmitted diagnosis codes associated with the past health claimsassociated with the member; and determine the set of expected diagnosiscodes to include in the message based on at least one of frequency ofchronic diagnosis codes found in the previously submitted diagnosiscodes, or recency of chronic diagnosis codes found in the previouslysubmitted diagnosis codes.
 19. A non-transitory computer readable mediumhaving instructions stored thereon that, when executed by a processor,cause a device to: receive an electronic communication transmitted froma sender computer, wherein the electronic communication is a currentelectronic health claim comprising one or more diagnosis codes for apatient of a healthcare provider and an identifier for the patient;determine whether the patient is covered by a health care plan providedby a payor by querying a database of prior electronic health claimsusing the identifier, wherein the database comprises information from atleast one of a plurality of healthcare providers and a plurality ofhealthcare payors; identify, responsive to determining that the patientis covered by the health care plan, a set of expected diagnosis codesassociated with a chronic disease or a chronic condition of the patient,wherein identifying the set of expected diagnosis codes includes to: i)query the electronic medical history for previously submitted diagnosiscodes associated with the patient, and ii) responsive to identifying atleast one previously submitted diagnosis code, determine a chroniccondition associated with the at least one previously submitteddiagnosis code, wherein the set of expected diagnosis codes are mappedto the chronic condition in the database; determine whether at least oneof the set of expected diagnosis codes is included in the one or morediagnosis codes of the current electronic health claim; when it isdetermined that at least one of the set of expected diagnosis codes isincluded in the one or more diagnosis codes of the current electronichealth claim, transmit the electronic communication to a payor computerassociated with the payor, wherein the payor: i) certifies the riskadjustment data associated with the electronic health claim is accurate,complete and truthful based on the determination that at least one ofthe set of expected diagnosis codes is included in the one or morediagnosis codes of the current electronic health claim, and ii) submitsdata associated with the certified electronic health claim to the CMSfor reimbursement; and when it is determined that at least one of theset of expected diagnosis codes is not included in the one or morediagnosis codes of the current electronic health claim, then: i) notsend the electronic communication to the payor computer, and ii)transmit a message to the sender computing identifying the expecteddiagnosis codes.
 20. The computer readable medium of claim 19, theinstructions further causing the device to track an incident rate forthe sender by updating the database to include an indication that thecurrent electronic health claim was missing the at least one of the setof expected diagnosis codes, wherein the incident rate for the sender iscompared to incident rates of other healthcare providers to trigger anaudit of the sender's practices and procedure.